| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
777 |
777 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
320 |
126 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
170 |
$14K |
| D0274 |
Bitewings - four radiographic images |
452 |
452 |
$13K |
| D0330 |
Panoramic radiographic image |
329 |
329 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
204 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
539 |
539 |
$11K |
| D1330 |
|
809 |
809 |
$9K |
| D1310 |
|
819 |
819 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
329 |
329 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
67 |
$6K |
| D2332 |
|
25 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$368.49 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$274.32 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$112.00 |